Healthcare Provider Details

I. General information

NPI: 1649762253
Provider Name (Legal Business Name): ROBIN SULLIVAN HARDIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL LN
FOREST MS
39074-4039
US

IV. Provider business mailing address

1 MEDICAL LN
FOREST MS
39074-4039
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4861
  • Fax: 601-469-1238
Mailing address:
  • Phone: 601-469-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number812434
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: